EFFECT OF PSYCHIATRIC CLINICAL POSTINGS ON ATTITUDES AMONG STUDENT NURSES AT HOSPITAL RAJA PEREMPUAN ZAINAB II KOTA BHARU, KELANTAN

Transcription

1 EFFECT OF PSYCHIATRIC CLINICAL POSTINGS ON ATTITUDES AMONG STUDENT NURSES AT HOSPITAL RAJA PEREMPUAN ZAINAB II KOTA BHARU, KELANTAN Norida Binti Muhammad, Chan Siok Gim* Open University Malaysia, Kelantan, Malaysia *Corresponding Author ABSTRACT Nurses play a key role in caring for the mentally ill and in rehabilitating them after an episode of illness. The nurses' attitude towards a patient is generally considered to be one of the basic factors contributing to the administration of total therapeutic nursing care. The purpose of this study was to examine whether attitudes towards mental patients improve after psychiatric attachment as well as the relationship between attitudes to psychiatry and intention to pursue psychiatry as a career. The study was conducted on sixty nursing students of fth semester at the Kolej Kejururawatan Kubang Kerian, Kelantan who are doing their psychiatric postings in Hospital Raja Perempuan Zainab II, Kota Bharu. The sampling technique for this study was convenient sampling. The instrument used for this study surveyed questionnaire developed by Brenda Happell (Happell, 2008). This quasi-experimental study measured changes in students' attitudes and satisfaction with clinical experience following a placement in mental health nursing. The questionnaire was administered to the nursing students on the rst and last day of their psychiatric clinical placement session. The ndings suggested that clinical experience during psychiatric clinical posting can positively in uence attitudes, preparedness for practice and the popularity of mental health nursing. Satisfaction with clinical experience was also high. The ndings of this study suggest that clinical postings had positive effects on nursing students' attitudes towards psychiatric patients and con dence in this eld of practice. Keywords : Attitudes, nursing students, mental patients, psychiatric postings INTRODUCTION According to the World Health Organization (WHO), the cost of not treating mental illness may be high both in personal and nancial terms whereby a signi cant indirect cost is made on the economy of a nation by mental illness. About 450 million people were estimated to be suffering from a mental health disorder and approximately one in four families currently had one or more of their members suffering from such disorders. Mental and behavioural disorders have a large impact on individuals, families and communities. Individuals suffer the distressing symptoms of disorders. They also suffer because they are unable to participate in work and leisure activities, often as a result of discrimination. They worry about not being able to shoulder their responsibilities towards family and friends and are fearful of being a burden to others. These families are required not only to provide physical and emotional support but also to bear the negative impact of stigma and discrimination present in all parts of the world. In Malaysia, health care providers in the primary health care and in the community routinely encounter persons with mental illness in their work. Nurses play a key role in caring for the mentally ill patients and in rehabilitating the mentally ill patients after an episode of illness. The nurse's attitude towards a patient is generally considered to be one of the basic VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING 3

2 factors contributing to the administration of total therapeutic nursing care. Furthermore, these attitudes, are to a great extent, the result of exposure to environments and experiences. Due to this reason, it is important to nd out the attitudes of nurses towards mentally ill and factors which might in uence these attitudes. Since the literature available in Malaysia in this eld is very limited owing to the absence of studies conducted, it is highly essential to conduct a study on mentally ill patient. The purpose of this study was to examine whether attitudes toward mental illness get improved during psychiatric attachment as well as the relationship between attitudes to psychiatry and intention to pursue psychiatry as a career. It also assessed the relationship between students' characteristics with their attitudes toward psychiatry and intention to pursue psychiatry as a career before and after psychiatric attachment. Prejudice occurs when a person judges another person because of a group they belong to. For many years, psychologists have tried to gure out how to overcome prejudice. One theory is the contact hypothesis. The contact hypothesis says that bringing members from different groups together will reduce prejudice. The idea is that exposure to others of different groups will reduce prejudice for those groups. Contact hypothesis which was mentioned by Allport (1954) was used as a theoretical framework for this study. It is also known as Intergroup Contact Theory. Interpersonal contact with one another is one of the most helpful ways to reduce the amount of prejudice and stereotypical notions that are present among different groups of majorities and minorities. The belief is that the opportunity for individuals to communicate with other people, allows groups to understand the different point of views and cultures. There are many studies that identi ed the impact of psychiatric mental health nursing theory and clinical education on attitudes related to mental illness. The need for caring people with mental health problems in general hospitals has increased. Nurses are the major providers of hospital care and have become an important resource in the delivery of mental health care. However, the attitudes and ability of many nurses in providing this care have been shown to be poor (Sharrock & Happell, 2002), and this may have a negative impact on care. Nurses' attitudes and the issues they believe affect their caring for people with mental health problems in rural hospitals, where demand for care is high, and support and education from mental health specialists are low. The last twenty years has seen major changes in mental health service policy and delivery in Malaysia in line with Mental Health Policy. The trend is towards care and treatment within the general health system of the community with the increased emphasis on the rights of people with mental illness. Research conducted in urban areas has found that many nurses responsible for care feel unprepared to support mental health needs, and have negative attitudes towards caring for people with mental health problems (Brinn, 2000). A qualitative descriptive study investigates nurses' attitudes to caring for people with mental illness, the issues that impact on their ability to provide care, and the effect of education, experience, and support. In 2003, 10 nurses from two wards in a rural hospital were interviewed. Participants from one ward had education and support from mental health nurses. Attitudes were found to be inextricably linked to issues that in uence nurses' ability to provide care. Dislike was apparent from nurses who suggested that it was not their role. Others identi ed fear, causing avoidance. Conversely, those receiving support and education described increased comfort, with some nurses expressing enthusiasm for mental health care, seeing it as integral to nursing. The priority of physical care, time constraints, environmental unsuitability, rural, and the lack of skill, knowledge, and mental health services reduced safety and effective care. A limited ability to help was reported, despite support for Mental Health Strategy goals. Positive experience promoted through education and support was required for nurses to improve care and attitudes. Notably, collaboration with mental health nurses was identi ed to be helping nurses overcome fear and increase competence in caring for people with mental illness (Reed & Fitzgerald, 2005). A study was conducted on Nursing Student's attitude change toward mental illness and psychiatric care recognition. The attitude towards mental illness were measured among 92 students of the seventh semester in the school of nursing of Athens University before (time 1) and after (time 2) the completion of 40 and 90 hours of lecture on clinical psychiatry and 4 VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING

3 clerkship, respectively (Madianos et al., 2005). The instrument used to measure attitudinal dimensions was the Cohen and Struening's opinions about mental illness (OMI) scale, which yields ve factors and was proven to be reliable and valid in previous studies. Hypothetical case vignettes were used to assess psychiatric case recognition. In factors A, B, and D statistically signi cant differences in attitudes towards mental illness between time 1 & time 2 were observed. It seems that the completion of training in psychiatric in uenced the students' opinion about mental illness as they expressed less authoritarianism and discriminatory beliefs as well as positive views about social integration of mentally ill persons. The group of students who failed to recognize the case vignettes satisfactorily also expressed negative views in four out of ve OMI scale factors. Another study had examined the in uence of a clinical attachment in psychiatry on medical students' attitudes towards psychiatry as a specialty and potential career. Medical students at Sydney Medical School were surveyed following an 8-week clinical attachment in psychiatry. Secondary analyses were sought to identify associations with variables such as age, gender and level of clinical experience as a medical student. Following a clinical attachment in psychiatry, 80% of students rated their attitude to psychiatry as more positive. Approximately 32% rated themselves as likely or very likely to choose a career in psychiatry. No differences were seen with respect to gender, age or stage of training. The quality of the teaching, enthusiasm of the clinical teachers, the holistic approach and scienti c basis of psychiatry were cited by students as factors in uencing attitudes. The clinical rotation in psychiatry is a signi cant factor in uencing medical student attitudes towards psychiatry. A study on undergraduate nursing and midwifery students' knowledge of and attitude towards, people with mental illness on a nonprobability sample of 235 under graduate nursing and midwifery students, had adopted modi ed version of the attitude and beliefs about mental health problems, professional and public view questionnaire was used. Instrument administered cross-sectional and longitudinal cohorts of students. The result showed that the students' knowledge about mental illness is similar to that of the general public. Further, there was a considerable difference in their attitude towards people with mental illness. In a study on the in uence of education of nursing students on the formation of attitudes toward psychiatric illness, attitudes towards mental illness were examined in 137 undergraduate students in the technological educational institute of Athens before and after completion of 105 hours of course of psychiatric nursing (Evangelou et al., 2005). The instrument used to assess the attitude was the Mental Illness Ideology Scale (CMI) scale about mental illness. In two out of ve CMI scale factors, statistically signi cant differences between two assessment times were observed. It seems that after psychiatric training, student's expresses less authoritarian. Views and their opinion toward social integration of mentally ill person were found to be more positive. Students with relatives with a mental health problem were found to be more negative toward social discrimination and more positive towards the provision of social care. It seems that theoretical training and clinical clerkship improve attitude towards mental illness. Hayman-White and Happell (2005) had adapted the Psychiatric/Mental Health Clinical Placement Survey for First Day of Placement scale to measure the impact of education and clinical placement on student nurses' preferences in career and in attitudes towards mental health nursing and patients (Hayman-White & Happell, 2005). They studied 784 student nurses, each placed in one of 21 compulsory clinical sites. Most of the students were in their second or third year of study. They addressed the relationship between attitudes, sense of preparedness, and career preferences of undergraduate nursing students prior to their psychiatric clinical experiences and found that few students wanted to pursue careers in mental health. Those who did hope to work in mental health overall had a more positive view of the actual worth of mental health as a profession whereas the other students did not. Students, on an overall view, did not feel well prepared to begin their rotation. On the other hand, a longitudinal study in Australia over the course of student nurses' entire educational experience, rather than pre/post-mental health content (McCann, Lu & Deegan, 2009) where the researchers studied a non-probability sample of student nurses (90 rst year, 46 second year, and 96 third year) measuring VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING 5

4 knowledge and attitudes toward mental illness using the attitudes and beliefs about mental health problems: professional and public views questionnaire. Findings indicated that students' initial attitudes were similar to those of the public. These attitudes did not change dramatically during the second year of nursing education. By the end of the third year, students began to believe in the value of therapeutic interventions. A small number of student nurses choosing to become psychiatric-mental health nurses urged to search the literature to nd what in uenced career choices for nurses. Various research articles correlated career choice with attitudes toward clients (Hayman- White & Happell, 2005; Melrose, 2002), career counseling as well as interest. Each of these aspects was important in determining career choice. Another study had revealed which of two variables, selfef cacy or interest, was predominant in career choice (Nauta et al., 2002). The implementation of a psychiatric clinical posting has been an integral component of Malaysian nursing academy curricula. Clinical posting provides students with the opportunity to apply theory to clinical practice in a psychiatric hospital setting. It has been acknowledged in the nursing education literature that the application of theoretical knowledge must be transferred into clinical practice (Munnukka et al., 2002). The theory provides information that assists nursing students in developing an understanding of the nurse's roles and the patients' needs in the clinical setting. Thus theory can inform practice, but theory alone does not provide the opportunity and reinforcement of clinical practice. Clinical posting, on the other hand, provides information that helps nursing students to implement nursing actions in a clinical setting. Consequently, the nursing theory can be applied and further understood with clinical posting. Recognizing the gravity of the problem, the investigator has chosen the problem of Fifth Semester nursing students for the study of the changes in their knowledge and attitudes before and after the intervention of the psychiatric nursing posting. So the investigator had gone through the details of needs for the study and designing of a conceptual research framework, to work out on the development of the tools. METHODOLOGY The research design of the present study is Quasi- Experimental with one group pre-test and post-test model. The design involves three mains steps. The rst step is the administration of the demographic questionnaires and rst-day placement questionnaires (pre-test) before the students go for their posting in the wards. The second step is the posting of the student nurses in the psychiatric wards (intervention), the nal and the third step is that of the administration of the last day placement questionnaires (post-test). Difference due to the application of psychiatric posting intervention is then determined by comparing the pretest and the post-test scores on knowledge and attitudes. The survey designed by Happell (2008) was modi ed with permission for the purpose of the study (Happell, 2008). The questions were organized from general to more speci c. They developed a Likert scale method to survey items. Primarily the instrument required participants to rank the nursing practice areas in which they would most likely to work after graduation in order of preference (1=most preferred to 7=least preferred). The sample size consisted of all sixty Fifth Semester nursing students who were doing their psychiatric nursing posting in Psychiatric Wards of Hospital, Raja Perempuan Zainab II, Kota Bharu, Kelantan. The questionnaire was pilot tested for internal consistency. The Cronbach's Alpha values for this instrument are and respectively. RESULT A series of one-sample t-tests were used to compare pre and post-placement responses to the clinical posting survey. The Psychiatric Clinical Placement Survey for First Day of Placement examined the following three areas of student nurses' perceptions and experiences: Ÿ Preparedness for clinical experiences (statements 1, 4, 7, 10, 14 17, and 22). Ÿ Ÿ Attitudes towards people experiencing a mental illness (statements 3, 5, 8, 9, 13 18, 19, 21, 23, and 24). Attitudes towards mental health nursing (statements 2, 6, 11, 12, and 20). In the post-placement survey, in addition to the above questions, 15 additional statements addressing student nurses' positive clinical experiences (statements 25 39) were included. 6 VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING

5 Most of the average post-placement scores were signi cantly different from the corresponding mean pre - placement scores. A signi cant and positive change is evident in students' attitudes towards people experiencing a mental illness as demonstrated by their greater tendency to acknowledge that the development of mental illness is not the fault of the individual, that people with a mental illness are not violent and unpredictable, and that the feelings of people experiencing mental illness are likely to be in uenced by the attitudes of others. Students also indicated a decreased anxiety about and greater con dence in providing care for people experiencing mental illness and generally felt safe within and more certain on how to act within the mental health environment. More positive the view of the value of mental health skills for nursing practice, a greater understanding of the role of the mental health nurses and an appreciation that mental health services can make a difference for people experiencing mental illness were also apparent following the completion of the clinical experience. Students felt more prepared for mental health nursing practice and suggested they were more likely to apply for a graduate nurse programme in this eld and to pursue mental health nursing as a career. Table 1. Differences between Pre- and Post- Placement Survey Statements 1. I feel well prepared for my psychiatric/mental health clinical placement. 2. Psychiatric/mental health nursing makes a positive contribution to people experiencing a mental health problem. 3. I am anxious about working with people experiencing a mental health problem. 4. I have a good understanding of the role of a psychiatric nurse. 5. I am uncertain how to act towards someone with a mental illness. 6. I will apply for a Post Basic Program in psychiatric/mental health nursing. 7. I feel con dent in my ability to care for people experiencing a mental health problem. 8. People with mental illness are unpredictable. 9. Mental illness is not a sign of weakness in a person. 10. My theoretical component of psychiatric/mental health nursing has prepared me well for my clinical placement. Pre Post t-value p (twotailed) * * * * * * * * * * 11. This clinical placement in psychiatric/mental health nursing will provide valuable experience for my nursing practice. 12. I intend to pursue a career in psychiatric/mental health nursing. 13. If I developed a mental illness I wouldn t tell people unless I had to. 14. My course has prepared me to work as a staff nurse in a medical-surgical ward. 15. My course has prepared me to work as a staff nurse in a pediatric ward. 16. My course has prepared me to work as a staff nurse in a psychiatric/mental health ward. 17. My course has prepared me to work as a staff nurse in a geriatric ward. 18. Someone I know has experienced a mental health problem. 19. When a person develops a mental illness it is not their fault. 20. Mental health services provide valuable assistance to people experiencing a mental health problem. 21. People with mental illness can t handle too much responsibility. 22. I feel safe about this psychiatric/mental health placement. 23. The way people with mental illness feel can be affected by other people s attitudes towards them. 24. People with mental illness are more likely to commit offences or crimes. *Signi cantly different at p < 0.05 When items 1-24 in Pre- test were computed as Pre-test and items 1-24 in Post- test were computed as Post-test and compared using the t-test, a signi cant difference was obtained as shown in Table 2 Table 2. Comparison between Pre-test and Post-test Scores Scores N Mean t value p value Pre-test * Post-test *Signi cantly different at p < 0.05 DISCUSSION The ndings from this study suggested that a number of signi cant changes in attitudes towards people experiencing a mental illness and sense of preparedness for work in the mental health eld have occurred following the completion of psychiatric clinical posting. Comparing scores on the 24 statements before and after clinical experience * 0.000* * * * 0.000* * * * * * * * VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING 7

6 demonstrates signi cant changes to most questions, with more positive attitudes to people with a mental illness and to the mental health nursing profession. This nding supports the literature in suggesting that clinical experience in mental health nursing produces more positive attitudes (Mullen & Murray, 2002; Wynaden et al., 2000). During the clinical posting, nursing students came in close contact with the psychiatric patients for two weeks. Based on Allport's (1954) contact hypothesis, close and pleasant interpersonal contact with people from different groups is probably the best way to achieve social harmony (Hogg & Abrams, 2007). Since Allport had rst formulated the contact hypothesis to improve intergroup relations between different races, it has been extended to mental illness stigma. Thus, researchers have focused on the role of contact in reducing stigma toward mental illness and have found that contact leads to improved attitudes and behaviour toward mental illness (Schulze et al., 2003; Thornicroft et al., 2008). It is now a generally accepted practice: under appropriate conditions, interpersonal contact is one of the most effective ways to reduce prejudice between majority and minority group members (Schiappa et al., 2005). Studies consistently reveal that people who are more familiar with mentally ill persons hold more positive attitudes toward them (Corrigan & Watson, 2002). An improvement in perceived preparedness for practice in the mental health eld was also evident. Students demonstrated more con dence in and less anxiety about caring for people within a mental health setting following the completion of the clinical experience. Regarding an increased sense of preparedness, participants professed that the theoretical component had prepared them for the experience. This supports the nding of a study that undergraduate nursing students feel less prepared for the mental health eld than they do for general nursing (Wynaden et al., 2000). A very high level of satisfaction with clinical experience was also observed through this study. This nding further supports the view that the perceived quality of clinical experience is likely to in uence nursing students' attitudes towards mental health nursing as a career (Henderson et al., 2007; Mullen & Murray, 2002; Wynaden et al., 2000). CONCLUSION While this study has produced valuable information, it is not possible to generalize to all nursing students. However, the current study provides a stronger basis for concluding that positive clinical posting and experience in psychiatry produces more positive attitudes towards mental illness and psychiatric nursing and contribute to a greater sense of preparedness for practice in the psychiatric ward. REFERENCES Allport, G. W. (1954). The nature of prejudice. Oxford, England: Addison-Wesley Brinn, F. (2006). Patients with mental illness: General nurses' attitudes and expectations. Nursing Standard. 14 (27), pp Corrigan, P. W. & Watson, A. C., (2002). The paradox of self-stigma and mental illness. Clinical Psychology: Science and Practice. 9, pp Evangelou, E., Adali, E., Koukia, F., Katostaras, M., Priami, G. & Toulia. (2005). The in uence of education of nursing students on the formation of attitude towards psychiatric illness. ICUS Nurses Web Journal. 23, pp 1-8. Reed, F., & Fitzgerald, L., (2005). The mixed attitudes of nurse's to caring for people with mental illness in a rural general hospital. International Journal of Mental Health Nursing, 14(4), pp VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING

7 Happell, B., (2008). The importance of clinical experience for mental health nursing Part 1: Undergraduate nursing students' attitudes, preparedness and satisfaction. International Journal of Mental Health Nursing. 17(5), pp Hayman-White, K. & Happell, B., (2005). Nursing students' attitudes toward mental health nursing and consumers: Psychometric properties of a self-report scale. Archives of Psychiatric Nursing. 19(4), pp Henderson, S., Happell, B. & Martin, T., (2007). Impact of theory and clinical placement on undergraduate students' mental health nursing knowledge, skills, and attitudes. International Journal of Mental Health Nursing. 16(2), pp Hogg, M.A. & Abrams, D., Intergroup behavior and social identity. The Sage handbook of social psychology: Concise student edition. pp Madianos, M.G., Priami, M., Alevisopoulos, G., Koukia, E. & Rogakou, E., (2005). Nursing students' attitude change towards mental illness and psychiatric case recognition after a clerkship in psychiatry. Issues in Mental Health Nursing. 26(2), pp McCann, T.V., Lu, S. & Deegan, J., (2009). Bachelor of Nursing students' beliefs about prognosis and outcomes for people with schizophrenia: a longitudinal study. International journal of mental health nursing. 18(1), pp Melrose, S. (2002). A clinical teaching guide for psychiatric mental health nursing: a qualitative outcome analysis project. Journal of Psychiatric and Mental Health Nursing. 9, pp Mullen, A. & Murray, L. (2002). Clinical placements in mental health: Are clinicians doing enough for undergraduate nursing students? International Journal of Mental Health Nursing. 11 (1), pp Munnukka, T., Pukuri, T. & Linnainmaa, P. (2002). Integration of theory and practice in learning mental health nursing. Journal of Psychiatric and Mental Health Nursing. 9, pp Nauta, M.M., Kahn, J.H., Angell, J.W. & Cantarelli, E.A., (2002). Identifying the antecedent in the relation between career interests and self-ef cacy: Is it one, the other or both?. Journal of Counseling Psychology. 49(3), pp 290. Schiappa, E., Gregg, P.B. & Hewes, D.E. (2005). The parasocial contact hypothesis. Communication Monographs. 72(1), pp Schulze, B., Richter Werling, M., Matschinger, H. & Angermeyer, M. (2003). Crazy? So what! Effects of a school project on students' attitudes towards people with schizophrenia. Acta Psychiatrica Scandinavica. 107(2), pp Sharrock, J. & Happell, B. (2002). The psychiatric consultation liaison nurse: Thriving in a general hospital setting. International Journal of Mental Health Nursing. 11(1), pp VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING 9

8 Thornicroft, G., Brohan, E., Kassam, A. & Lewis-Holmes, E. (2008). Reducing stigma and discrimination: Candidate interventions. International Journal of Mental Health Systems. 2(1), pp 1. Wynaden, D., Orb, A., McGowan, S. & Downie, J. (2000). Are universities preparing nurses to meet the challenges posed by the Australian mental health care system? Australian and New Zealand Journal of Mental Health Nursing. 9(3), pp VOL. 8 (3) JANUARY 2017 THE MALAYSIAN JOURNAL OF NURSING